Language used to convey HIV infection risk is important

Abstract

The recent Comment by Jens Lundgren and Andrew Phillips1Lundgren J Phillips A Prevention of HIV transmission by antiretroviral therapy.Lancet HIV. 2018; 5: e108-e109Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar raises important issues about how we convey risk of HIV transmission to those who need to know about it: an audience that includes medical practitioners but also their patients, people living with HIV conditioned to think they present a risk to their sexual partners. Yet the science tells us otherwise. The authors say of HIV treatment “Antiretroviral drugs can prevent sexual transmission of HIV. If used consistently as pre-exposure prophylaxis (PrEP) by uninfected people, the risk of becoming infected is substantially reduced. And when used effectively by people already infected, the risk of onward transmission is very low, even for condomless sex acts. In populations extensively and repeatedly tested for HIV, and when antiretroviral therapy (ART) is initiated immediately on testing positive, transmission risk seems to decrease.” That language is problematic. “Very low” is only right in that you cannot prove something will not happen. We have to be more cognisant of expressing that in ways people can relate, in ways that reflect that we have seen zero cases of HIV transmission through sex when one partner is positive but has a sustained undetectable viral load, the other negative, in a series of larger scale trials. I think it is possible to speak in a way that is consistent with the science but more helpful. The CDC, for example, uses this language: “People who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”2McCray E Mermin J HIV & AIDS in the United States: information from the CDC's Division of HIV/AIDSS Prevention.https://docs.wixstatic.com/ugd/de0404_fab89a3aaeeb406bbd7898d0e90d5dac.pdfDate accessed: April 27, 2018Google Scholar Anthony Fauci, Director of NIAID, NIH, said at the 2017 US Conference on AIDS “the science really does validate that U=U (Undetectable equals Untransmittable)”.3Prevention Access CampaignUSCA 2017—September 9, 2017; Dr Anthony S Fauci on U=U.https://www.youtube.com/watch?v=LffrIfipgwc&list=PLMuV5dq7YMFuaMfvhexWqHiFKJ9iiMu_n&index=1&t=3sDate accessed: April 26, 2018Google Scholar The Editorial in this journal in November4The Lancet HIV. U=U taking off in 2017. Lancet HIV 4: e475.Google Scholar gets it right: “The fact that people infected with HIV who are virally suppressed cannot sexually transmit the virus to others is now accepted in the HIV/AIDS community as a result of accumulating evidence since the early 2000s.” It is not just semantics but rather a recognition that precise use of language is important. Suggesting that those living with HIV with undetectable viral loads pose an unproven but slight risk to others unnecessarily stigmatises millions. It perpetuates myths that exist even within the ranks of medical practitioners. Thus, the article cries out for further commentary, given the potential to mislead, to confuse, and even to create legal problems for those living with HIV. For more on the Prevention Access Campaign see www.preventionaccess.org For more on the Prevention Access Campaign see www.preventionaccess.org I declare no competing interests. Prevention of HIV transmission by antiretroviral therapyAntiretroviral drugs can prevent sexual transmission of HIV. If used consistently as pre-exposure prophylaxis (PrEP) by uninfected people, the risk of becoming infected is substantially reduced.1 And when used effectively by people already infected, the risk of onward transmission is very low,2 even for condomless sex acts.3 In populations extensively and repeatedly tested for HIV, and when antiretroviral therapy (ART) is initiated immediately on testing positive, transmission risk seems to decrease. Full-Text PDF U=U taking off in 2017The fact that people infected with HIV who are virally suppressed cannot sexually transmit the virus to others is now accepted in the HIV/AIDS community as a result of accumulating evidence since the early 2000s. In early 2016, the Undetectable=Untransmissable (U=U) slogan was launched by the Prevention Access Campaign to promote the finding. The campaign has been rapidly gathering momentum, having been endorsed by more than 400 organisations from 60 different countries since its launch. Last month, the US Centers for Disease Control and Prevention (CDC) joined the movement by endorsing the science in a letter released on National Gay Men's HIV/AIDS Awareness Day. Full-Text PDF Language used to convey HIV infection risk is important – Authors' replyWe thank Bob Leahy for bringing the wording we used on the risks of transmission in people with suppressed plasma viral load to the attention of the readership. We agree with Anthony Fauci's interpretation that people “who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner”, and we agree that this better conveys the risk to a broad audience than the wording we used in the article. Full-Text PDF